To understand the hypothesized relationship between social roles and sick role
acceptance, this chapter outlines Lazarus and Folkman’s (1984) transactional model of stress and coping (TMSC) and presents a conceptual framework for understanding (a) personal appraisal of the demands associated with accepting the sick role diagnosis of hypertension, and (b) the internal evaluation of resources that lead to coping behavior and ultimately health-promoting behaviors. Additionally, this chapter provides a discussion of additional stress and coping theories in the literature that have been applied specifically to explore the impact of stress on chronic illness among African Americans. Finally, the TMSC, in conjunction with role theory, is foundational in this dissertation study. Each theory informs the study conceptual model, which is presented at the end of the chapter.
The Transactional Model of Stress and Coping (TMSC)
Originally proposed by Richard Lazarus (1966) in his book Theory of Psychological Stress and the Coping Process, the TMSC was the first theoretical model to emphasize the important role of cognitive appraisal (self-evaluation in how a person reacts, feels, and behaves in encounters with the environment) and coping (cognitive and behavioral efforts to manage demands) as mediators of stressful person-environment interactions (Folkman, Lazarus, Dunkel- Schetter, DeLongis, & Gruen, 1986; Lyon, 2011). Lazarus’s views on stress were a departure
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from earlier stress and coping theories which viewed stress as a response to (a) strain or negative or disturbing factors in the environment (Levi, 1974; Selye, 1956) or (b) a stimulus (Symonds, 1947; Welford, 1973), treating life events as the stressors to which an individual responds (Lyon, 2011). Instead, Lazarus viewed stress as a transactional process, suggesting that stress does not exist in a given situation or event (e.g., being diagnosed with high blood pressure) but rather is the result of transactions (continuous interactions and adjustments) between the person and the environment (Lazarus & Folkman, 1984; Lyon, 2011).
Effective adaptation to stressful events involves a complex relationship of several different factors including the situation or event itself, personal appraisal of the impact of that event, a review of coping resources, and ultimately the use of coping strategies. The TMSC is a cognitive framework useful for understanding how persons in their environment move through the process of evaluating and coping with a perceived stressful event. This dissertation uses Lazarus’s definition of stress as “occurring when an individual perceives that the demands of an external situation are beyond his or her perceived ability to cope with them” (Lazarus, 1966, p. 9). Theoretically, stress arises when individuals perceive that they cannot adequately cope with the demands being made on them or with the immediate threats to their well-being (Lazarus, 1966; Lazarus & Folkman, 1984). Essentially there is a perception of discrepancy between the demands of a potential threat and resources available to cope with those demands (Folkman, Schaefer, & Lazarus, 1979; Lazarus, 1966). The way in which individuals interpret their ability to effectively cope with a threat can often become more important than the threat itself. How a stressor is perceived may either facilitate or impede ability to cope with the event.
This dissertation hypothesizes that women will evaluate available coping strategies for a diagnosis of hypertension based on their perception of resource availability when considering
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existing roles. Further, it is hypothesized that an assessment of incongruence between a woman’s current role obligations and the demands and responsibilities of the new sick role will cause stress (conflict), which will ultimately result in a failure to adhere to medical recommendations. TMSC Cognitive Appraisal
Individuals are constantly evaluating the significance of life events and their possible impact on our well-being. How they cope with the meaning of those events is directly related to the process of appraisal. Cognitive appraisal is the process through which individuals interpret and respond to potentially stressful events. Here, a person evaluates the importance of an interaction with the environment by asking, “What does this mean to me personally?” (Lazarus & Folkman, 1987). There are three types of appraisal central to the TMSC: primary appraisal, secondary appraisal, and reappraisal. The basic model is illustrated in Figure 3.
Figure 3. The Transactional Model of Stress and Coping
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Primary appraisal. When faced with a stressor, a person considers the relevance of the potential threat. Essentially “the person evaluates whether he or she has anything at stake in this encounter” (Folkman et al., 1986, p. 993). In a primary appraisal, a person makes a judgment about whether a person-environment transaction is irrelevant, benign-positive, or stressful. When a transaction is appraised as irrelevant, it is seen as having no significance for personal
wellbeing. An appraisal of benign-positive would result in a positive assessment of the transaction as neither taxing nor being in excess of the person’s resources. However, if the transaction is appraised as stressful, then the person has determined that the demands of the situation outweigh the available resources (Lyon, 2011).
When a transaction has been appraised as stressful, it is seen as having the potential for harm/loss, threat, or challenge. In harm/loss, actual harm has already occurred, for example having been diagnosed with hypertension by a medical professional. A threat here represents the potential for future harm (e.g., potential for coronary heart disease). Finally, a challenge
represents an opportunity for gain or benefit. Harm/loss and threat appraisals are characterized by negative emotions, such as anger, fear, or resentment, whereas challenge appraisals are characterized by pleasurable emotions, such as excitement and eagerness (Folkman, 1984).
Commitments and beliefs. An individual’s appraisal can be influenced by commitments. Commitments are defined as an individual’s general belief about his or her ability to control important outcomes, revealing what is important to the individual and what has meaning for him or her (Folkman, 1984). These commitments can be thought of as personal contemplations of what is at stake when facing this new demand. For a woman faced with acceptance of the sick role, contemplations can include support of a spouse, lost wages from missed employment, or familial responsibilities. Any encounter that involves a strongly held belief or commitment will
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be evaluated as significant with respect to personal well-being to the extent that the expected outcome harms or threatens that commitment (Folkman, 1984). In this dissertation research, those commitments could be considerations that include existing social roles.
Secondary appraisal. It is the perception of a threat that prompts the secondary
appraisal process and initiates the evaluation of coping options. This secondary appraisal process addresses the question, “What, if anything, can I do?” or “What actions can be taken?” Coping resources would include physical (i.e., health, strength, and energy), social (i.e., social support systems), psychological (i.e., beliefs and personal faith), and material assets (i.e., financial resources; Folkman, 1984). It is important to note that the TMSC is not a theory of “stages” with appraisals occurring one after the other (Shweder, 1993).Instead the secondary appraisal
happens simultaneously with the primary appraisal, and at times the secondary appraisal becomes the cause of a primary appraisal.
Situational appraisal. An event can also be appraised in terms of its controllability. Situational appraisals of control, much like commitments in primary appraisal, are a part of the secondary appraisal process. These are a person’s beliefs or judgment about the possibilities for control over the stressful encounter (Folkman, 1984). Situational appraisals are the result of the individual’s evaluation of the stress demand and the subjective evaluation of available coping resource options and ability to implement them. If individuals attribute controllability to factors external to themselves, they are less likely to believe there is efficacy in confronting the problem (Fleishman, 1984).
Reappraisal. Finally, “reappraisal is the process of continually evaluating, changing, or relabeling earlier primary or secondary appraisals as the situation evolves”. (Lyon, 2011.p 9). After a period of reappraisal, what was initially seen as a threat may now be seen as a challenge
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(a positive opportunity), irrelevant-benign. Ultimately, the conclusions drawn during these appraisal processes determine emotions and coping behaviors (Lyon, 2011).
TMSC Coping
Coping behaviors are an important piece of the stress process. The ways people cope with stress affect their psychological, physical, and social well-being (Folkman & Lazarus, 1980). Whether strategies to cope are adaptive or maladaptive depends on the event, personal appraisal, and coping strategies. Coping is defined as the “constantly changing cognitive and behavioral efforts to manage specific external and/or internal demands that are appraised as taxing or exceeding the resources of the person” (Lazarus & Folkman, 1984, p. 141). It involves the management of the stressful situation, using one or more management strategies (e.g., master the situation, minimize importance, or avoid situation). Different people may employ different types of coping behaviors. The choice of coping behaviors can moderate the degree to which
psychological distress results from social stress (Fleishman, 1984).
Coping strategies. Two forms of coping are described in the TMSC: those focused on altering the troubled person-environment relationship that is causing the distress (problem- focused coping), and efforts aimed at decreasing stressful emotions (emotion-focused coping; Folkman et al., 1986). In a study of coping with daily stressful events among a community of middle-aged men and women, Folkman and Lazarus (1980) found that problem-focused coping was used more frequently in encounters that were appraised by the person as changeable, while emotion-focused coping was used more frequently in encounters that were appraised as more unchangeable. Figure 4 presents a diagram of the internal process of the cognitive process that determines what type of coping an individual is likely to use.
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Figure 4. Cognitive Process Leading to Determination of Problem vs. Emotion-Focused Coping
Source: Wells-Di Gregorio (n.d., p. 11)
Stress, Coping, and Health Outcomes
Individuals experiencing stressful events are at risk for both physical and psychological illness (Outlaw, 1993), and when coping is inadequate, this tends to compound existing stress (Lazarus, 1990). The literature clearly illustrates that stress and coping behaviors can negatively impact individual well-being. In general, there is familiarity with the negative impacts of stress and maladaptive coping behaviors that result in, for example, alcoholism, drug addiction, and eating disorders, as well as intimate partner violence (e.g., Ayer, Harder, Rose, & Helzer, 2011; Fox, Bergquist, Hong, & Sinha, 2007; Shortt, Capaldi, Kim, & Tiberio, 2013; Sulkowski,
Dempsey, & Dempsey, 2011). Additionally, research has linked stress to the onset of anxiety and depressive symptomology, which can significantly impact emotional well-being and diminish the ability to maintain healthy relationships and accomplish goals (Fan, Blumenthal, Watkins, & Sherwood, 2015).
Stress is the generic cause of, or contributor to, several diseases, but not the specific cause of any one (House, 1974). The literature has presented strong correlational evidence between stress and chronic illnesses such as stroke, hypertension, heart disease, and metabolic
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syndrome (a combination of cardiovascular risk factors related to hypertension, abdominal obesity dyslipidemia, and insulin resistance). More specifically, chronic work-related stress has been shown to impact metabolic syndrome (Chandola, Brunner, & Marmot, 2006), hypertension (Vrijkotte, Van Doornen, & De Geus, 2000), and CHD (House, 1974; Marmot, Bosma,
Hemingway, Brunner, & Stansfeld, 1997). Egido and colleagues (2012) found that psycho- physical stress factors (i.e., quality of life, high levels of anxiety or depression, social and work status, family responsibilities, and cultural differences) are associated with stroke. Stress is a physiological demand placed on the body, which is like a threat; in response, the individual finds ways to appraise and cope with the threat (Nevid & Rathus, 2003). Prolonged stress coupled with the inability to effectively cope with demands can have undesirable consequences on health outcomes. This dissertation focuses specifically on the stress (sick role diagnosis) and the coping (evaluation of multiple roles) behaviors of African American women with hypertension.
Stress, coping, and health outcomes in African American women. Although not a homogeneous group, African Americans have a shared history of shouldering the burdens of racism, oppression, and discrimination. These burdens have had an impact that lingers even today, as evidenced by current health disparities. “Health disparities can stem from any combination of stressors, including economic determinants, education, geography and
neighborhood, environment, lower-quality health care, inadequate access to health care, inability to navigate the health care system, provider ignorance or bias, and stress” (Bahls, 2011, p. 3). From slavery through the present, examples of persistent stressors in this population have included work and labor stress (e.g., slave labor, marginalization after emancipation, Jim Crow laws), acculturative stress (i.e., stress related to adaptation to a dominant culture), environmental stress (e.g., SES, neighborhood segregation), and perceived and actual discrimination and racism
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(e.g., daily microaggressions) ( e.g. Anderson, 1991; Mims, Higginbottom & Reid, 2001; Sue, Capodilupo, & Holder). Over time, chronic stress can result in both physical and behavioral consequences and can result in cumulative disadvantages (Braveman, 2011).
Prior research has examined the theoretical relationships between racism, stress, and coping on health outcomes specific to African Americans in general and African American women and high blood pressure in particular. The following sections briefly review findings from that body of literature.
Racism and Health
Racism is a chronic stressor, and chronic psychosocial stress has long been hypothesized to be a risk factor for hypertension (Brondolo, Love, Pencille, Schoenthaler, & Ogedegbe, 2011; Subramanyam et al., 2013). Although race is a social construct, the use of racial categories to divide and discriminate against groups of individuals is tangible. Importantly, these racial categories predict variations in health status (Williams, 1997). For example, stress due to
experiences with racism has been shown to impact birth outcomes for African American women (Nuru-Jeter et al., 2009). However, evidence of a relationship between racial discrimination and blood pressure has been inconsistent across studies (Barksdale, Farrug, & Harkness, 2009; Brondolo et al., 2011). To unpack the relationship between racism and health, several studies have examined the physiological impact of racism on health outcomes (Paradies, 2006; Pascoe & Smart Richman, 2009; Williams & Mohammad, 2009). Several examples of that literature follow.
Racism and high blood pressure. Specific to hypertension, Krieger and Sidney (1996) assessed the relationship between self-reported experiences of racial discrimination and blood pressure among participants enrolled in the CARDIA study (Coronary Artery Risk Development
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in Young Adults), a study that examined the evolution of cardiovascular risk factors. Participants were asked about experiences of racial discrimination and unfair treatment in several settings (i.e., at school, getting a job, at work, getting housing, getting medical care, on the street or in a public setting, and from the police or in the courts). African American women reported they were most likely to experience discrimination on the street or in public settings, followed closely by at work. The researchers also evaluated blood pressure by two social classes (i.e. working class or executive/professional/supervisory). Their results indicated higher blood pressure among working class African American women who reported keeping discrimination to themselves compared to those who told others and tried to do something about it (Kreiger & Sidney, 1996). Additionally, lower blood pressures were found among professional African American women who reported that they typically challenge unfair treatment and had not experienced
discrimination.
Williams and Neighbors (2001) reviewed the scientific evidence related to high blood pressure and racism, examining studies conducted in laboratory environments as well as epidemiological studies with community samples. In one example of the reviewed literature, Fang and Myer’s (2001) laboratory study of African American and White men found that there was increased cardiovascular reactivity among both groups when exposed to racially charged material (a filmed portrayal of racism)—but the increase was no more than that produced by any other anger-provoking stressors (Williams & Neighbors, 2001). Although there was no
difference by race, the authors stated that because African Americans have higher exposure to racial stress and non-racial stress, they may carry a heavier burden in terms of cardiovascular reactivity and thus, an increased burden of cardiovascular disease (Fang & Myers, 2001; Williams & Neighbors, 2001). The review also included laboratory research by Clark (2000),
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who found that in a small sample of African American women (N = 39), women who scored highly on a perceived racism scale had higher diastolic blood pressure.
Other studies found less evidence of a link between racism and high blood pressure. For example, Peters (2004) examined the impact of exposure to a chronic stressor (perceived racism) on the development of chronic stress emotions (trait anger, trait anxiety, and trait depression) and hypertension among African Americans adults. The study found that while participants had high levels of perceived racism, it was not however associated with blood pressure. Interestingly, the highest levels of blood pressure were found in older adults who had reported the lowest level of perceived racism. The author suggested some relationship to the idea of internalized oppression whereby unfair treatment is perceived as “deserved” and not discriminatory (Peters, 2004). Similarly, Barksdale, Farrug, and Harkness (2009) found that although racial discrimination was not correlated with blood pressure, surprisingly, emotions like sadness and frustration were significantly but negatively correlated with blood pressure.
Racism can occur on multiple levels: individual (i.e., targeted person to person), interpersonal (i.e., directly perceived discriminatory interactions between individuals in their institutional roles or as public or private individuals), internalized (i.e., accepting what others believe), and institutional (i.e., policies and procedures in resulting unequal treatment; Brondolo et al., 2011). In a review of the empirical evidence directly and indirectly linking multiple levels of racism to hypertension, Brondolo and colleagues found that while there was evidence that racism appears to affect risk for high blood pressure, the effects are complex (Brondolo et al., 2011). Specifically, while high blood pressure may increase as a result of institutional racism and interpersonal racism, direct evidence linking individual racism and interpersonal racism to high blood pressure diagnosis in this study was weak.
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What is clear from the literature is that how a person copes with the stress of racism and oppression impacts health outcomes in ways that are not always easy to measure. Several frameworks and hypotheses on stress and coping behaviors specific to African Americans are proposed in the literature. A brief summary of those theories follows.
Explanatory Theories of Stress and Coping Specific to African Americans
Several researchers with interests in the impact of stress on the African American population have proposed culturally specific hypotheses describing the pathways between chronic stress and coping mechanisms. This section briefly reviews four of these related frameworks.
Weathering hypothesis. The weathering hypothesis posits that African Americans experience health deterioration earlier in life as a consequence of the cumulative impact of repetitive social and economic adversity, as well as political marginalization (Geronimus, 1991; Geronimus, Hicken, Keene, & Bound, 2006). This accumulation of disadvantage over the life course may also contribute to acceleration of the biological aging process (Geronimus et al., 2006; Levine & Crimmins, 2014; Whitfield, Thorpe, & Szanton, 2011). As a result African Americans experience earlier disease mortality and morbidity. The weathering hypothesis has been utilized to explain early-age of onset of diseases normally seen in older age (Geronimus et al., 2006) including high blood pressure (Geronimus, Bound, Keene, & Hicken, 2007).
Allostatic load. The allostatic load framework is sometimes referred to as the mechanism for weathering (Whitfield, Thorpe, & Szanton, 2011). Allostasis is the process by which the body adapts to a stressor in order to maintain homeostasis (the internal processes of the body that regulate its response to challenges and demands; Mays, Cochran, & Barnes, 2007). Allostaic